As seniors, we oversee our junior trainees’ cases while coordinating the case flow through the operating rooms with our front desk during call shifts. While the junior residents and SRNAs check our “stat rooms” and emergent airway boxes prior to preparing for their respective cases, I’ll visit the pharmacy to grab syringes of my two favorite rescue drugs: epinephrine and succinylcholine.
Epinephrine is a natural stress catecholamine and an incredibly versatile drug in perioperative medicine. Bronchospasm? Give epinephrine. Anaphylaxis? Give epinephrine? Profound vaso-vagal reaction… or bradycardia… or hypotension… give epinephrine. It’s a great temporizing measure while diagnosing and treating the underlying problem.
Succinylcholine is a fast acting depolarizing neuromuscular blocker. Although there are known contraindications, if there’s an acute laryngospasm or an emergent airway, I already have my paralytic of choice ready to go! In fact, if I’m intubating a tenuous cardiac patient, I’ll often include a little epinephrine with succinylcholine and a hypnotic during my induction process.
For the overwhelming majority of my call shifts, I’ll return both syringes unused to the pharmacy. I just have peace of mind with these two in my pocket. 😀
What about bronchospasm, same dose? Especially in the pediatric population where it is a problem we come across quite often…. Thanks
I’m not entirely sure about the pediatric population, but in adults, I’m comfortable giving 10-20 mg of IV ketamine and/or 10 mcg boluses of IV adrenaline titrated to effect after trying albuterol.
As usual thanks a lot
Well I usually carry along ephedrine and rocuronium. We don’t have succinylcholine and I’ve never actually been quite comfortable with epinephrine ( or adrenaline as we call it here). Still remember when I used it in obstetric anaesthesia some 3 months ago for spinal induced hypotension which did not respond to ephedrine…. BP was okay after 100 mcg admistred in a peripheral but the number of extrasystoles the patient made scared the hell out of me….
Regarding epinephrine and the mentioned indications, what posologies do you usually use and what administration route?
As usual thanks for sharing and keep it coming.
I stick with the IV route (even peripheral IVs) and usually 10 mcg boluses of adrenaline for hypotension or bradycardia (titrating to effect). For anaphylaxis, I don’t think there’s a commonly accepted dose for the IV route, so I’ll give 10-20 mcg IV while running fluids, removing the trigger, etc. The proarrhythmic effects of vasopressors (especially dopamine and epinephrine) are side effects I’ll accept in order to treat more acutely life threatening problems. 🙂